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{\footer\pard\s16\tqr\tx9552\tx13608\plain\f0\fs16\i Original template compiled by Monash Division of General Practice, March 2006\par}\pard\s16\qc\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs24 <<Miscellaneous:Practice Letterhead>>{\*\txfieldend}\plain\f1\fs24\par\pard\s16\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt40\trpaddr30\trpaddb40\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw20\clcbpat5\cellx9638\pard\widctlpar\intbl\pard\intbl\qc\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\b TEAM CARE ARRANGEMENTS \plain\f0\fs24\b\cb3\chshdng0\chcfpat0\chcbpat3  - \plain\f1\fs24\b\cb3\chshdng0\chcfpat0\chcbpat3 MBS ITEM No 723 \plain\f1\fs24\b (CORONARY HEART DISEASE)\plain\f1\fs24\cb4\chshdng0\chcfpat0\chcbpat4\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs24\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx4819\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b Patient\loch\f1\hich\f1 \'92s Name:\plain\f1\fs20  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Patient Demographics:Full Name>>{\*\txfieldend}\plain\f1\fs24\cell\plain\f1\fs20\b Date of Birth:\plain\f1\fs20  {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Patient Demographics:DOB>>{\*\txfieldend}\plain\f1\fs24\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx4819\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Contact Details:\plain\f1\fs20\tab\plain\f1\fs20\b\cell Medicare or Private Health Insurance Details:\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx4819\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Patient Demographics:Full Address>>{\*\txfieldend}\plain\f1\fs20\cell{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Patient Demographics:Medicare Number>>{\*\txfieldend}\plain\f1\fs20\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Patient Demographics:Health Insurance>>{\*\txfieldend}\plain\f1\fs20\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx4819\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b Details of Patient\loch\f1\hich\f1 \'92s Usual GP:\plain\f1\fs20\cell\plain\f1\fs20\b Details of Patient\loch\f1\hich\f1 \'92s Carer (if applicable):\plain\f1\fs20\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx4819\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Doctor:Name>>{\*\txfieldend}\plain\f1\fs20\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Doctor:Full Address>>{\*\txfieldend}\plain\f1\fs20\par\cell\par\par\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\par\plain\f1\fs20\b Date of last Care Plan/Team Care Arrangements (if done): \plain\f1\fs20  {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0044007c007c007c00310030007c00200020002f00200020002f0020002000200020000000}{\*\txfieldtext \plain\f1\fs20 <<Date of last Care Plan/TCA>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|D|||10|  /  /    "}}{\fldrslt{\plain\f1\fs20 <<Date of last Care Plan/TCA>>}}}}\plain\f1\fs20\par\par\plain\f1\fs20\b Other notes or comments relevant to the patient\loch\f1\hich\f1 \'92s Team Care Arrangements:\plain\f1\fs24  \plain\f1\fs20\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\par\par\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b\par PAST MEDICAL HISTORY\plain\f1\fs20\par\par{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfieldbin\txfielddata 0000}{\*\txfieldtext \plain\f1\fs20 <<Clinical Details:History List>>}}\plain\f1\fs20\b\par\par FAMILY HISTORY\plain\f1\fs20\par\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Clinical Details:Family History>>{\*\txfieldend}\plain\f1\fs20\b\par\par MEDICATIONS \par\par{\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Clinical Details:Medication List>>{\*\txfieldend}\plain\f1\fs20\par\par\plain\f1\fs20\b ALLERGIES\par\plain\f1\fs20\par{\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfieldbin\txfielddata 0000}{\*\txfieldtext \plain\f1\fs20 <<Clinical Details:Allergies>>}}\plain\f1\fs20\par\par\plain\f1\fs20\b\page Patient\loch\f1\hich\f1 \'92s Name: {\*\txfieldstart\txfieldtype0\txfieldflags26}\plain\f1\fs20 <<Patient Demographics:Full Name>>{\*\txfieldend}\plain\f1\fs24\par\plain\f1\fs20\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\clcbpat5\cellx9638\pard\widctlpar\intbl\pard\intbl\qc\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs24\b\cb3\chshdng0\chcfpat0\chcbpat3 TEAM CARE ARRANGEMENTS  - MBS ITEM 723 \plain\f0\fs24\b (CORONARY HEART DISEASE)\par\plain\f0\fs18\b Applies to acute coronary syndromes, myocardial infarction, coronary angioplasty with/without stenting, and bypass surgery. Similar guideline for other vascular disease (peripheral and cerebrovascular)\plain\f1\fs20\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs2\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx3212\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx6424\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9636\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs20\b Goals - changes to be achieved\plain\f0\fs20\cell\plain\f0\fs20\b Required treatments and services including patient actions\plain\f0\fs20\cell\plain\f0\fs20\b Specific arrangements for treatments/services (when, who, and contact details)\plain\f1\fs20\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx3212\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx6424\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9636\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs20 Patient to have a clear understanding of \plain\f0\fs18 coronary heart disease and the patient's role in managing the condition\plain\f1\fs20\cell\plain\f0\fs20 Patient education\plain\f1\fs20\cell\plain\f0\fs20 GP\par Practice nurse\plain\f1\fs20\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx3212\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx6424\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9636\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18 Medication management\plain\f1\fs20\cell\plain\f0\fs18 Ensure correct use of medications.  Undertake Home Medicine Review \plain\f1\fs20\cell\plain\f0\fs18 GP\par Pharmacist\plain\f1\fs20\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx3212\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx6424\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9636\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs20 Maintain healthy diet and optimum weight range (including lifestyle aspects of lipids and blood pressure)\plain\f0\fs18\cell Maintain healthy nutrition and weight control\cell GP\par Dietitian\par Other allied health educator\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx3212\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx6424\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9636\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Maintain physical activity\cell Development of exercise program suitable to needs of patient\cell GP\par Cardiac rehab\par Exercise physiologist\par Other allied health educator\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx3212\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx6424\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9636\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Smoking cessation\cell Smoking cessation program\cell GP\par Quit program\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx3212\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx6424\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9636\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Minimise ongoing cardiac symptoms\cell Optimise medical management\cell GP\par Cardiologist or other specialist\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx3212\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx6424\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9636\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f0\fs18 Co-morbidity, e.g. diabetes\cell Optimise medical management\cell GP\par Medical specialist\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx3212\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx6424\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9636\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Improve wellbeing\cell Manage depression\cell GP\par Psychologist/psychiatrist/counsellor\cell\intbl\row\pard\trowd\trgaph30\trleft0\trpaddl30\trpaddt20\trpaddr30\trpaddb20\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx3212\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx6424\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9636\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080 Reduce social isolation\cell Linkages to community services\cell GP\par Counsellor/social worker\cell\intbl\row\pard\pard\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\par\plain\f1\fs20\b Copy of Team Care Arrangements offered to patient? \plain\f1\fs20  {\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f1\fs20 <<Copy of TCA offered to patient?>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|B|||1|N"}}{\fldrslt{\plain\f1\fs20 <<Copy of TCA offered to patient?>>}}}}\plain\f1\fs20\par\plain\f1\fs20\b\par Team Care Arrangements added to the patient\loch\f1\hich\f1 \'92s records?  {\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f1\fs20 <<TCA added to patient record?>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|B|||1|N"}}{\fldrslt{\plain\f1\fs20 <<TCA added to patient record?>>}}}}\plain\f1\fs20\par\par\plain\f1\fs20\b Copy / relevant parts of the Team Care Arrangements supplied to other providers?  {\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f1\fs20 <<Copy of TCA supplied to other providers?>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|B|||1|N"}}{\fldrslt{\plain\f1\fs20 <<Copy of TCA supplied to other providers?>>}}}}\plain\f1\fs20\par\par\plain\f1\fs20\b Referral forms for Medicare allied health and dental care services completed?  {\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f1\fs20 <<Referral forms for Medicare AHPs completed?>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|B|||1|N"}}{\fldrslt{\plain\f1\fs20 <<Referral forms for Medicare AHPs completed?>>}}}}\plain\f1\fs20\par [For referral forms call 1800 067 307, go to www.hic.gov.au/providers/forms or look under "Supplied" templates]\plain\f1\fs20\b  \plain\f1\fs20\par\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\cellx4819\clvertalt\cellx9638\pard\widctlpar\intbl\pard\intbl\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b Date service was completed:  {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0044007c007c007c00310030007c00200020002f00200020002f0020002000200020000000}{\*\txfieldtext \plain\f1\fs20 <<Date service completed>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|D|||10|  /  /    "}}{\fldrslt{\plain\f1\fs20 <<Date service completed>>}}}}\plain\f1\fs20\cell\plain\f1\fs20\b Proposed Review Date:\plain\f1\fs24   {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c0044007c007c007c00310030007c00200020002f00200020002f0020002000200020000000}{\*\txfieldtext \plain\f1\fs20 <<Review date (6 months recommended)>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|D|||10|  /  /    "}}{\fldrslt{\plain\f1\fs20 <<Review date (6 months recommended)>>}}}}\plain\f1\fs20\cell\intbl\row\pard\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par\trowd\trgaph30\trleft0\trpaddl30\trpaddt0\trpaddr30\trpaddb0\trpaddfl3\trpaddft3\trpaddfr3\trpaddfb3\clvertalt\clbrdrl\brdrs\brdrw10\clbrdrt\brdrs\brdrw10\clbrdrr\brdrs\brdrw10\clbrdrb\brdrs\brdrw10\cellx9638\pard\widctlpar\intbl\pard\intbl\box\brdrs\brdrw5\brsp80\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tx8640\tx9360\tx10080\plain\f1\fs20\b\par I have explained the steps and any costs involved, and the patient has agreed to proceed with the Team Care Arrangements.  {\txfielddef{\*\txfieldstart\txfieldtype1\txfieldflags26}{\*\txfielddatadef\txfielddatatype1\txfielddata 230043005500530054004f004d0023007c0042007c007c007c0031007c004e000000}{\*\txfieldtext \plain\f1\fs20 <<Steps and costs explained, patient agreed>>}{\field{\*\fldinst { HYPERLINK "CUSTOM" \\l "|B|||1|N"}}{\fldrslt{\plain\f1\fs20 <<Steps and costs explained, patient agreed>>}}}}\plain\f1\fs20\b\par The patient also agrees to the involvement of other health providers and to share their clinical information (without / with restrictions). \plain\f1\fs20  {\txfielddef{\*\txfieldstart\txfieldtype2\txfieldflags26}{\*\txfielddatadef\txfielddatatype2\txfielddata 230043005500530054004f004d0023007c004c007c007c007c00350031007c005900650073002c00200077006900740068006f007500740020007200650073007400720069006300740069006f006e0073007c005900650073002c002000770069007400680020007200650073007400720069006300740069006f006e0073007c004e006f000000}{\*\txfieldtext \plain\f1\fs20 <<Patient agrees to AHPs and sharing information>>}{\field{\*\fldinst { HYPERLINK \\l "#CUSTOM#|L|||51|Yes, without restrictions|Yes, with restrictions|No"}}{\fldrslt{\plain\f1\fs20 <<Patient agrees to AHPs and sharing information>>}}}}\plain\f1\fs20\par\plain\f1\fs20\b\par  \plain\f1\fs20 GP\loch\f1\hich\f1 \'92s Signature:  ________________________________________________\tab Date:___________________\par\pard\intbl\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\cell\intbl\row\pard\pard\tx567\tx1134\tx1701\tx2268\tx2835\tx3402\tx3969\tx4536\tx5103\tx5670\tx6237\tx6804\tx7371\par }